Case Study: Mrs. Jones

Client Assessment

• Client Name: Mrs. Martha Jones
• Age: 82 years old
• Medical Diagnosis: Hypertension, COPD, Emphysema, Gout, Mild Chronic Kidney Disease, Mild Arthritis, Intermittent bouts of nausea/diarrhea

Client Perception of Health Needs

Mrs. Jones perceives her health needs to include managing her chronic conditions (COPD, hypertension, arthritis, gout) and addressing her frequent shortness of breath, fatigue, and swelling in her feet.

Client Goals for Health

Mrs. Jones aims to manage her symptoms effectively, maintain as much independence as possible, and reduce her frequency of shortness of breath and fatigue.

Nursing Care Plan

Nursing Diagnosis and Planning

1. Actual Problem: Ineffective Airway Clearance related to COPD and emphysema as evidenced by shortness of breath and reduced oxygen saturation (SaO2) at 88% on room air.
   • SMART Goal: Mrs. Jones will demonstrate effective airway clearance with SaO2 levels maintaining above 92% on room air within the next 24 hours.
   • Interventions:
     1. Administer prescribed bronchodilators (e.g., Spiriva, Salbutamol) to improve airflow and reduce shortness of breath.
     2. Encourage and assist Mrs. Jones with deep breathing exercises and the use of an incentive spirometer to enhance lung expansion.
   • Rationale: Bronchodilators help open the airways, making it easier to breathe, while deep breathing exercises and incentive spirometry help prevent atelectasis and improve oxygenation.
   • Evaluation: Assess SaO2 levels hourly and monitor for signs of improved airway clearance such as reduced breathlessness and increased lung sounds.
2. Risk/Potential Problem: Risk for Imbalanced Nutrition related to decreased appetite and frequent episodes of nausea and diarrhea.
   • SMART Goal: Mrs. Jones will maintain her current weight and demonstrate a balanced nutritional intake by consuming at least 75% of her meals over the next two weeks.
   • Interventions:
     1. Collaborate with a dietitian to develop a meal plan that accommodates her preferences and digestive tolerance.
     2. Provide small, frequent meals and snacks that are easy to digest and appealing to Mrs. Jones.
   • Rationale: A tailored meal plan and smaller, frequent meals can help prevent nutritional deficiencies and minimize gastrointestinal discomfort.
   • Evaluation: Monitor daily food intake and weight weekly, adjusting the plan as necessary based on Mrs. Jones’s tolerance and preferences.
3. Wellness/Health Promotion: Readiness for Enhanced Self-Management related to arthritis and gout management.
   • SMART Goal: Mrs. Jones will verbalize understanding and demonstrate appropriate self-care techniques for managing arthritis and gout within the next week.
   • Interventions:
     1. Educate Mrs. Jones on proper joint protection techniques and the importance of adhering to her medication regimen for arthritis and gout.
     2. Provide resources and referrals for physiotherapy and occupational therapy to assist with mobility and ADLs.
   • Rationale: Education and therapy can empower Mrs. Jones to manage her conditions effectively and maintain independence in her daily activities.
   • Evaluation: Assess Mrs. Jones’s understanding of the educational materials and her ability to apply self-management techniques during follow-up visits.

Implementation of Nursing Interventions

• Intervention 1: Administer prescribed bronchodilators as ordered.
  • Rationale: To improve lung function and ease breathing in patients with COPD and emphysema.
  • Evidence: Literature supports bronchodilators as first-line therapy for COPD to enhance airway patency.
• Intervention 2: Collaborate with a dietitian to address nutritional needs.
  • Rationale: To ensure that Mrs. Jones receives adequate nutrition to maintain weight and manage gastrointestinal symptoms.
  • Evidence: Proper nutrition is vital for elderly patients, especially those with chronic conditions, to maintain energy levels and overall health.

Nursing Evaluation

• Evaluation Criteria:
  • For Airway Clearance: Monitor SaO2 levels and assess lung sounds for improvement.
  • For Nutrition: Track weight and meal consumption to evaluate the effectiveness of the dietary plan.
  • For Self-Management: Assess Mrs. Jones’s ability to perform joint protection techniques and her adherence to the medication regimen.
• Client Responses and Findings:
  • Evaluate Mrs. Jones’s feedback on the interventions and adjust the care plan based on her needs and preferences.
• Further Nursing Actions:
  • Adjust the care plan as needed based on the outcomes and Mrs. Jones’s evolving health status, including follow-up appointments and continuous education.